AMD Follow-Up Note (Anti-VEGF/OCT)

Date: [Date]

Clinic/Location: [Clinic or Location]

Provider: [Provider Name, Credentials]

Visit Type: [Retina follow-up / OCT + possible injection / Injection-only]

Treatment Context: [Current regimen summary with laterality and strategy, e.g., "nAMD OD on treat-and-extend aflibercept 8-week interval"]

(Laterality (OD/OS) must appear with every disease-activity statement, OCT finding, and procedure. When information is unavailable, document why and its impact on decision-making. Do not copy forward prior findings without updating for today's encounter.)

Chief Complaint / Interval History

[Reason for visit with laterality and timing] [Last injection: date, agent, eye] [Patient-reported visual status since last visit: better/stable/worse, by eye] [New symptoms: distortion, scotoma, floaters, pain, redness—specify eye and onset] (Format as a concise paragraph. If last injection details unavailable, document why and how this affects today's plan.)

Examination

Vision: [VA with correction status, OD and OS]

IOP: [Values by eye with method]

Anterior Segment: [Pertinent findings by eye, or "unremarkable"]

Posterior Segment: [Dilated status; macula, disc, periphery findings by eye—note hemorrhage, exudate, PED, fibrosis, GA if present]

OCT Macula

(Omit this section entirely if OCT not performed. If omitted, document elsewhere why and how activity was otherwise assessed.)

Indication: [Clinical reason for OCT, e.g., "Evaluate nAMD activity to guide anti-VEGF interval"]

OD: [CST if available; IRF present/absent; SRF present/absent with location; PED status; other relevant findings]

OS: [CST if available; IRF present/absent; SRF present/absent with location; PED status; other relevant findings]

Comparison: [Improved / Stable / Worse vs prior; specify what changed]

Impression: [Activity status per eye: active / inactive / equivocal]

Plan Impact: [One sentence linking OCT findings to today's treatment decision]

Assessment

1. [Diagnosis, eye] — [active / inactive / minimally active] — [brief basis]
2. [Fellow eye status with laterality and basis]
3. [Other relevant diagnoses affecting vision or interpretation]

Plan

(Document for each eye with nAMD. If injection deferred, state clinical basis and return precautions.)

[OD / OS]: [Inject / Defer] — [Agent if injecting; note if switching and why] — [Extend / Maintain / Shorten] to [interval in weeks] — [Rationale, e.g., "no IRF/SRF, stable VA"] — Follow-up [timing, OCT planned yes/no] — Risks, benefits, alternatives, and post-injection warning signs discussed; patient agreed to proceed [or elected to defer].

(Repeat for second eye if bilateral nAMD.)

Procedure: Intravitreal Injection

(Include only when injection performed today. Omit entirely if no injection. For bilateral injections, document each eye separately below.)

[OD / OS]:

• Procedure: Intravitreal injection [eye]
• Indication: [Eye + diagnosis]
• Consent: Informed consent obtained (Note if off-label use disclosed)
• Time-out: Completed — correct patient, eye, and drug verified
• Technique: [Anesthesia; povidone-iodine antisepsis; lid control method]
• Medication: [Drug, dose/volume, lot number, expiration]
• Injection site: [Quadrant, distance from limbus]
• Outcome: [Tolerance; complications or "none"; post-procedure vision/IOP if checked]
• Post-procedure instructions: Return urgently for pain, decreased vision, increasing floaters, photophobia, or redness

(Duplicate the above for each injected eye.)